The cardinal symptoms are pain, vomiting, obstinate constipation, tympany and tumor. Nausea is not always an important symptom, vomiting is very important, and we must consider the kind, the onset, frequency, persistency, the gulping and the character of the dejecta. In general peritonitis the vomiting is persistent till death. In local peritonitis the vomiting is only for one or two hours.
In appendicitis the patient rarely vomits more than once, but if it continues there is a streptococcus infection or the peritoneum associated with the appendix. In local peritonitis, whether from the pus tubes, gall bladder or appendix, the vomiting and obstructive symptoms are of short duration, but long in general peritonitis and intestinal obstruction. True fecal vomiting is very serious and shows the obstruction to be below the ileocecal valve. Never wait for fecal vomiting, for even though you may relieve the obstruction, the delay is at the sacrifice of the life of the patient. Note whether the vomit has the fecal odor. In primary mechanic obstruction there is no elevation of temperature; if elevated then it is not mechanic. The full abdomen may be the result of undue accumulation of fat, meteorism or ascites. When obstruction of ileus is without strangulation it is the result generally of a neoplasm. Neoplasms internal and external to the bowel are generally followed by periodic obstruction. The strangulated ileus causes marked impression; the obstruction of ileus may occur without producing any marked symptoms. In septic ileus there is always elevation of temperature, and generally results in defective innervation. In appendicitis and inflamed gall bladder the entire abdomen may be tender by palpation but the tender spot will be found at “McBurney’s point” or under the costal arch about the ninth rib.
In appendicitis, cholelithiasis, and renal disease, besides the tenderness over each of the organs, the direction of the pain is diagnostic. In appendicitis the course of the pain is toward a point just above the umbilicus; in cholelithiasis toward the right infrascapular region; and in renal disease toward the pubes following the course of the genitocrural nerve. Appendicitis is frequently mistaken for obstruction. True ileus is often due to appendicitis.
The facies in ileus is suggestive; the face is pale, eyes are sunken, more or less cyanosis, the nose pinched and the skin clammy.
The tympany is according to the situation, there is very little if any when the obstruction is high up. Local meteorism or colonic tympany may give a tumor-like formation as in volvulus.
Pain should be well considered, the locality, the sensitive spot as directed by the patient, as a guide to the seat of disturbance; the character, colicky, continuous or lancinating. Does it completely subside in remission? The duration of pain, has it continued all through the illness as in peritonitis, or is it intermittent as in calculus of cystic duct or of ureter?
Can we always diagnose between tonic and atonic varieties? History of patient helps but it is generally unintelligent. Tight strangulation in the small intestine occurring suddenly is accompanied by intense colicky pains with nausea and vomiting, the ejection of the stomach contents being often violent or even projectile. Collapse with such symptoms is early. One prominent symptom of obstruction from contracted bowel is ileus following a meal two or three hours. A collapsed bowel indicates that the obstruction is above and is a guide to the seat of obstruction. Repeated obstructions indicate multiple adhesions and in the experience of the writer they have not been permanently benefited either by medical and adjuvant treatment or by operation. If the ascending colon is not contracted the obstruction is above the ileocecal valve. The quantity of water in the colon will indicate whether the trouble is there.
An adult colon will hold two to four quarts.
The nearer the seat of the strangulation is to the stomach the more urgent is the need for speedy relief. A strangulation in the large intestine is not immediately accompanied by violent vomiting but there is tenesmus and griping pain with the discharge of mucus and if there is intussusception, blood or bloody mucus.
It should not be overlooked that in elderly individuals constricting neoplasms of the colon are far from rare, and that acute obstructive symptoms from this cause with the passage of blood by the anus may simulate intussusception.
Hiccough and the frequent regurgitations of intestinal fluid without nausea are common in the later stages of ileus and should be regarded as ominous.
Have, if possible, the patient stand, for the examination. Observe the contour of the abdomen both standing and lying, also with head and legs extended; when legs are flexed have patient take normal and deep respiration. Observe any undue prominence of the abdominal veins, as the Caput Medusae. Pes oedema indicates obstruction of the inferior vena cavá. Enlargement of epigastric arteries indicates obstruction of iliac arteries or the abdominal aorta. Bartlett in his excellent work on Clinical Medicine says, “In all cases of enlargement of the abdominal veins in which the origin of the difficulty is not clear an attempt should be made to determine the direction in which the blood flows through the dilated vessel. For example, there may sometimes be seen an enlarged vein running upwards in the mid-axillary line. When it is dependent upon obstruction of the inferior vena cava, or of the portal vein, the blood current is upwards; when on the other hand, it originates in obstruction of the superior vena cava the flow is downwards.”
Sensitive points over abdomen and rigid muscles should be carefully observed, Coproliths must not be taken for tumors. Gersuny’s “adhesive sign” may assist in deciding the character of these fecal tumors. We must not forget that a fecal tumor may be perforated with a central canal through which the fecas may pass.
Palpation should be done with entire flat surface of the hand, especially during respiration.
Auscultation of the abdomen with the stethoscope, especially in acute peritoneal diseases, is of great value.
Constipation and its many causes should be thoroughly inquired into.
If a patient has a history of chronic and persistent constipation and a section is performed, for pelvic or abdominal neoplasms, carefully search before closing, the abdomen for a constricted bowel. The writer has seen two fatal cases of ileus paralyticus where post mortem examinations revealed constriction as the cause of the obstipation. The “ribbon like stool” is not a positive symptom of a constricted bowel. Examine blood for leukocytes.